Patient Information:

Physician Information:

Form Instructions:

This form must be completed in its entirety.

The patient’s condition at the time of transport must be documented.

Medical Necessity criteria must be clearly documented according to CMS PCS requirements.

If this PCS is for a repetitive patient (identified as a patient requiring three (3) or more transports within a ten (10) day period), a physician must sign this form prior to the first transport. This form may serve for a period of sixty (60) days.

Medicare requires under 42CFR, Part 401.40(d) that ambulance providers obtain a Physician’s Certification Statement (PCS), signed by a listed clinician, for the provision of non-emergency transportation. This form has been designed to assist clinicians, Medicare beneficiaries, and ambulance provider in determining if medical necessity has been met. Authorized signers please complete the medical necessity section of this form and then sign the form, listing your credential.

Medical Necessity Criteria:

To be completed by a clinician who is employed or contracted by the facility where the beneficiary is being treated, and who has knowledge of the beneficiary’s condition at the time the transport was ordered or the service was being furnished.

(*) Asterisked fields require additional information.

*Requires continuous oxygen, airway monitoring or suctioning

*Provide further details; note if patient can self-administer oxygen

Is comatose and requires monitoring

Is seizure-prone and requires monitoring

Has an unrepaired or recent fracture/joint replacement and is unable to bear weight and must remain immobile

Is ventilator dependent

Ventilator Mode:

Ventilator Rate:

Tidal Volume:

FiO2:

PEEP:

Pressure Support:

Additional Comments:

Requires continuous IV therapy

Requires EKG cardiac monitoring

*Requires restraints and/or sedation

*Provide further details

*Has severe contractures

Right Upper

Right Lower

Left Upper

Left Lower

All of the Above

*Has decubitus ulcers and requires wound precautions/special handling

*Provide further details, such as stage, location and any contact precautions

Is exhibiting signs of a decreased level of consciousness/awareness and is a danger to self or others

Pain medication given prior to transport needs continuation of care and advanced cardiac life support (ACLS) monitoring

*Patient requires services not available at this healthcare facility

*Describe services not available at this healthcare facility

*Patient is bed-confined, as defined by 42CFR, Part 410.40(d)(1), Medicare establishes a beneficiary as bed-confined if they are: unable to get up from bed without assistance, AND unable to ambulate, AND unable to sit in a chair or wheelchair. ALL THREE conditions must be met at the time of transport.